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Retrospective Study

Retrospective analysis of survival of patients with


squamous cell carcinoma of the maxilla after primary
resection and elective bilateral neck dissection: An
institutional experience
Balakrishnan Ramalingam, Vijay Ebenezer

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DOI:
10.4103/2231-0746.83155
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Department of Oral and Maxillofacial Surgery, Sree Balaji Dental College and Hospital,
Pallikaranai, Chennai, India
Address for correspondence:
Dr. Balakrishnan Ramalingam, Department of Oral and Maxillofacial Surgery,
Sree Balaji Dental College and Hospital, Pallikaranai, Chennai, India.
E-mail: bala4_us@yahoo.com

ABSTRACT
Background: A retrospective analysis of the 5-year survival rates of patients who underwent treatment for oral squamous cell
carcinoma (OSCC) of the maxillary region was performed to analyse the prognostic factors for patients survival. Materials and
Methods: Twenty-four patients with SCC of the maxillary region, who underwent treatment at our hospital between 1999 and
2009 were included in the study. The patients underwent primary surgical resection and elective bilateral neck dissection. The
patients with tumor positive margins were referred for chemo-radiotherapy after surgery. Results: The overall 5-year survival
rate was 25%. The patients who had recurrence had presented with T3 or T4 lesions only. Of the patients who died, 14 out of
the 18 were those who had tumor-positive margins and had undergone radiotherapy following surgery. Conclusions: Primary
surgical treatment of SCCs of the maxillary region along with elective bilateral neck dissection yielded some improvement in
survival rates, and can therefore be seen as a valuable strategy. Tumor-free resection margins and early detection of the lesion
are the most important indicators for favorable prognosis.
Keywords: Maxillectomy, squamous cell carcinoma, survival

INTRODUCTION
With an increase in the abuse of smokeless tobacco, there has
been an increase in the incidence of oral malignancies, the
most common of them being squamous cell carcinomas (SCC;
>90%).[1] The current estimates of age-standardized incidence
and mortality associated with oral SCC (OSCC) are 6.6/100,000
and 3.1/100,000 in men and 2.9/100,000 and 1.4/100,000
in women, respectively.[2] A recent study on site prevalence
of OSCC conducted in the western Uttar Pradesh has ranked
the most prevalent sites as buccal mucosa (63.75%), followed
by retromolar area (15%), floor of the mouth (11.25%), lateral
border of the tongue (3.75%), labial mucosa (3.75%) and palate
(2.5%).[3] Survival in patients with SCC of either the hard palate
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or maxillary alveolus is significantly influenced by T-stage and


cervical nodal metastases.[4] The routine therapy usually consists
of three strategies: radiotherapy, chemotherapy and radical
surgical resection of the tumor including the lymph node levels
involved according to the TNM staging. The three strategies are
used in different ways and combinations and many concepts are
described in the literature.[5-7]
Indications for postoperative radiotherapy (PORT) included
Stage III or IV OSCC according to the 2002 criteria of the
American Joint Committee on Cancer, the presence of perineural
invasion or lymphatic invasion, the depth of tumor invasion
or a close surgical margin. In a recent study by Fan et al, the
3-year overall and recurrence-free survival rates of OSCC
Annals of Maxillofacial Surgery | January - June 2011 | Volume 1 | Issue 1

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Ramalingam and Ebenezer: Retrospective analysis of survival of patients with squamous cell carcinoma of the maxilla

patients treated with PORT were estimated to be 73% and 70%,


respectively. Univariate analysis revealed that differentiation,
perineural invasion, lymphatic invasion, bone invasion, location
(hard palate and retro-molar trigone), invasion depths > or
=10 mm, and margin distances < or =4 mm were significant
prognostic factors. The presence of multiple significant factors
of univariate analysis correlated with disease recurrence. The
3-year recurrence-free survival rates were 82%, 76% and 45%
for patients with no risk factors, one or two risk factors, and
three or more risk factors, respectively.[8] In an another study
by Lin et al, it has been found that the primary tumor site and
neck stage are the prognostic predictors in advanced-stage oral
cancer patients who received radical radiotherapy. The primary
tumor extension and radiotherapy technique did not influence
survival.[9]
However, surgery is considered a better treatment strategy than
concurrent chemoradiation therapy for achieving positive survival
outcomes. Wang et al, after a 10-year review of cases in a tertiary
care referral center found a higher surgical salvage rate in patients
with hard palatal cancer who had local recurrence or neck relapse.
Soft palate or infratemporal fossa involvement had poor outcomes.
Ulcerative tumor features, tumor volumes larger than 10 ml and
local recurrent tumors that could not undergo salvage surgery also
had poorer survival outcomes. Surgical management is still the
first choice for patients with hard palate or alveolus SCCs even
when patients had local or regional recurrence.[10]

Table 1: TNM Staging


T1
T2
T3
T4

3
0
9
12

N1
N2a
N2b
N2c
N3

3
2
1
1
0

M1

Table 2: Grading
G1
G2
G3

6
11
7

Table 3: Tumor localization


Survival
Alveolus
Hard palate
Soft palate
Alveolus and hard palate
Hard palate and soft palate
Palate and pterygoids
Alveolus, hard and soft palate
Palate and maxillary sinus
Palate, maxillary sinus and orbit
Palate, maxillary sinus, ethmoids
Palate, maxillary sinus, orbit, ethmoids and skull
base

4
3
3
3
2
1
3
2
1
1
1

2
1
0
1
1
0
0
1
0
0
0

Table 4: Survival rates


In this retrospective study at our hospital we evaluated the
treatment of SCC of the maxilla and the paranasal sinuses
primarily by surgical means and to identify risk factors for the
patients survival.

MATERIAL AND METHODS


Twenty-four patients with SCC of the maxillary alveolus, hard
palate and/or soft palate confirmed by incisional biopsy, who
were treated at the Department of Oral and Maxillofacial Surgery
at our hospital between 1999 and 2009 with a minimum of
5-year follow-up were retrospectively analyzed and included
in the study. All patients underwent surgical resection of the
tumor along with elective bilateral lymph node resection without
preoperative radiotherapy or chemotherapy as per decisions
taken by the tumor board. TNM staging was determined as per
the clinical and radiological findings. The tumor was graded
after histopathological examination of the biopsy specimen.
The patient data was obtained from case sheets and the medical
records [Tables 1-4]. The surgical procedure was based on the
TNM staging and the location of the tumor. The lesions were
excised along with a minimum of 1 cm symptom-free margin
after obtaining due consent from the patients. However, in
some cases tumor-free margins could not be ascertained due
to the position of the tumors. Approach was determined by
the size and the location of the tumor. Intraoral approach was
used for small lesions, large lesions required Weber Fergusson
approach. Midline lesions were removed by midfacial degloving
[Figures 1-9]. In cases where the tumor extension was beyond the
ethmoid or the orbit, the incisions were modified accordingly.
Care was taken to preserve palpabrae and conjunctiva for orbital
prosthesis. The reconstruction of the defect after resection was
Annals of Maxillofacial Surgery | January - June 2011 | Volume 1 | Issue 1

Parameter

Age (yrs) <50


Age (yrs) 50
Female gender
Male gender
T1
T2
T3
T4
N- 0
N 12
Grade 1
Grade 2
Grade 3
Perineural invasion + ve
Lymphatic invasion + ve
Bone invasion + ve
Invasion depth > 10 mm
Resection margin > 1.5 cm
Surgery alone
Surgery and RT
Overall duration of RT 50
Overall duration of RT >50
Overall dosage of RT <65 gy
Overall dosage of RT 65

No. of No. of patients who


patients survived disease
free for 5 years
6
18
9
15
3
0
9
12
17
7
6
11
7
2
12
10
7
6
9
15
10
5
9
6

2
4
3
3
3
0
2
1
5
1
3
2
1
0
2
1
1
6
5
1
1
0
1
0

5-year
survival
%
33.3
22.2
33.3
20.0
100.0
0.0
22.2
8.3
29.4
14.3
50.0
18.2
14.3
0.0
16.7
10.0
14.3
100.0
55.6
6.7
10.0
0.0
11.1
0.0

decided according to the size and staging. Most defects could


be closed by local flaps, the buccal fat pad or pedicled temporal
flap immediately after resection. Some cases with large defects
were referred for free microvascular flaps. An obturator prosthesis
was applied to facilitate closure of the defect. After resection,
the specimens were sent for histopathological examination to
ascertain tumor-free margins.
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Ramalingam and Ebenezer: Retrospective analysis of survival of patients with squamous cell carcinoma of the maxilla

Figure 1: (a, b) Preoperative appearance of the tumor

Figure 2: Preoperative CT

Figure 3: Weber Fergusson incision

Figure 4a: Exposure

Figure 4b: Resection

RESULTS
All patients underwent surgical removal of their tumors. Bilateral
neck dissection was performed simultaneously. Sixteen patients

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were reconstructed using local flaps and eight patients were


referred for microvascular reconstruction and were provided a
temporary prosthetic obturator. Eighteen patients succumbed to
the tumor in the 5-year follow-up. Of them, four had undergone
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Ramalingam and Ebenezer: Retrospective analysis of survival of patients with squamous cell carcinoma of the maxilla

Figure 5: Closure of the defect using split skin graft harvested from the
inner aspect of the thigh

Figure 6: Immediate postoperative appearance with temporary prosthesis

Figure 7: Healing of skin graft

Figure 8: Flexible obturator replacing the temporary one

Figure 9: (a) Postoperative appearance, (b) Postoperative occlusion, (c) Postoperative smile

surgical resection alone and 14 had undergone surgery followed


by Radiotherapy.
In six patients, the tumor could not be resected with a clear
1-cm border due to its extensive spread, where resection would
Annals of Maxillofacial Surgery | January - June 2011 | Volume 1 | Issue 1

involve damage to vital organs. In nine patients, the margins were


tumor positive microscopically. All these 15 cases were referred
to the chemo-radiotherapy team for management. While only
seven cases exhibited nodal involvement, 12 of the resected
lymph nodes exhibited metastasis. Fifteen patients survived for

45

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Ramalingam and Ebenezer: Retrospective analysis of survival of patients with squamous cell carcinoma of the maxilla

24 months and were able to live a life of acceptable quality.


The radiation doses for patients who received postoperative
radiotherapy was between 46 and 76 Gy. Chemotherapeutic
agents used were cisplatin and 5-fluorouracil. The survival rates
were tabulated and compared. The survival rate of patients who
exhibited perineural spread (0%), bone invasion (10%), lymphatic
invasion (16.7%) and those with tumor thickness more than 10
mm (14.3%) exhibited a lower rate of survival.

DISCUSSION
SCC of the maxilla and paranasal sinuses occur less frequently
than that of the buccal mucosa, floor of the mouth or lip. However,
these tumors are noticed much later by the patients themselves
due to their asymptomatic nature. The invasion of the maxillary
sinus or the retromaxillary region manifests much later than that
of the buccal region.[11] Eighty-seven percent of the 24 cases that
were chosen for primary surgical intervention to the Oral and
Maxillofacial Department were T3 and T4-sized lesions.
The tumor board has three primary options of treatments to
choose from surgery, radiotherapy and chemotherapy. While
multimodal treatment is currently followed widely, the primary
treatment is often the one that determines the prognosis and the
quality of life of the patient. Choice of surgery as the primary
treatment choice has been very successful at our hospital with
2-year survival of 62.5%. Patients with extensive spread beyond
the maxilla, into the orbit, the ethmoids and skull base required
an adjuvant radiotherapy when tumor-free margins could not be
ascertained.
However, the role of postoperative radiotherapy is questionable.
In his comparative study of 85 patients with SCC of the maxillary
sinus who received all of their treatment at The University of
Texas M.D. Anderson Cancer Center between the years 1971
and 1986, Stern et al.,[12] conclude that they found no statistical
difference between patients who were treated surgically alone
and patients who received a postoperative radiotherapy after
tumor resection. The overall 5-year survival rate in his study
was about 50%. Therefore chemotherapy or radiotherapy are
avoided due to the adjuvant complications of osteoradionecrosis,
blindness[13] limitations in mouth opening, stomatitis, nausea,
xerostomia, pneumonia and hemogram changes with leucopenia
or pancytopenia, etc. Surgical therapy after radiation has also been
avoided due to the protraction of the treatment and the reduction
of blood supply to the maxilla postradiation. Prolonged overall
radiation time has been associated with poorer survival and local
control. Late severe toxicity from chemo-radiation treatment of
tumors has been assessed to be a significant problem in longterm survivors.[14]
However, in some cases where the surgery could be debilitating
and deforming, and the prognosis is poor, in order to preserve
the quality of life, the extension of the resection is limited and
adjuvant therapies are given priority. Especially in cases where
extension of the tumor involves the orbit, it is essential to weigh
the cons of facial deformity. Since it has also been observed that
even after exenteration of the orbit, the prognosis is often poor
and therefore some authors suggest the preservation of the orbit
to improve the patients quality of life without compromising
46

survival.[15,16] However, in our cases, we were able to provide


the patient with a satisfactory prosthesis and a survival of more
than 4 years by choosing surgery as the primary treatment and
chemo-radiation as secondary treatment.
Similar conclusions are drawn by Dulguerov et al, in a systematic
review of 220 patients.[17] They conclude that patients who
underwent exenteration of the eye had a longer survival than
those who opted not to. Similarly, those who underwent surgery
had the highest survival rate, (79%) followed by those who had
surgery and radiation (66%). Those who had radiation alone had
the lowest survival rates (57%). In cases where tumor-negative
resection margins could not be achieved because of the invasion
of the tumor, primary surgery and postsurgical radiotherapy were
advised. The achievement of negative resection margins has been
a crucial prognostic factor.[14] In our study, 15 patients had positive
resection margins and 14 of them (93.3%) died due to disease
recurrence and spread.
The presence of positive lymph nodes is quite rare in cases
of maxillary SCC compared with other subsites in the oral
cavity.[18] In our series, only seven patients (29.4%) showed
metastases at the time of operation but all received therapeutic
neck dissection. Chiu et al, performed a chart review on all
patients undergoing primary surgery and elective bilateral
neck dissection for supraglottic carcinoma between 1989 and
2000 and found that the 2-year survival increased from 72% to
82.6%. [19] Simental et al also recommended elective neck
dissection because of the better functional outcome compared
with radical neck dissection.[20] SCC has a predilection for cervical
metastasis and since occult metastasis cannot be entirely ruled
out, it was decided that elective neck dissection be performed in
a single stage than to wait for the tumor to recur. All cases where
complete tumor resection could be ascertained, primary closure
of the defect was done. In cases where the tumor clearance could
not be ascertained, the patients were provided with a temporary
prosthesis and reconstruction advised after radiotherapy.
A retrospective analysis of 62 patients diagnosed with SCC of
the maxillary sinus treated with curative intent between 1994
and 1999 revealed a 3- and 5-year overall survival of 38% and
35% and a disease free survival of 29% and 26%, respectively.
Patients with metastases in the cervical nodes fared adversely and
died between 4 and 22 months of treatment. Pattern of failure
in the series revealed that 45% of patients failed at the primary
site. Isolated local failure occurred in 38.7% of the patients and
was the most common pattern of recurrence.[21]

CONCLUSION
Our treatment protocol of primary surgical excision and elective
neck dissection followed by radiation for cases with tumorpositive margins has yielded a survival rate of 25%. Since
recurrence occurred only in T3, T4 patients and more often
in patients with tumor-positive margins, we conclude that the
complete excision of the tumor and its early detection are the
prognostic factors for disease control. Lymphatic spread, thickness
of the tumor, bone invasion and perineural invasion are also
prognostic factors of importance.
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Cite this article as: Ramalingam B, Ebenezer V. Retrospective analysis of


survival of patients with squamous cell carcinoma of the maxilla after primary
resection and elective bilateral neck dissection: An institutional experience.
Ann Maxillofac Surg 2011;1:42-7.
Source of Support: Nil, Conflict of Interest: None declared.

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